Download Pleural Diseases

Pleural Effusions
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Terrence Coulter, MD
Ferrell-Duncan Clinic
Cox Health System
Springfield, MO
DEFINITION
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Pleural effusion is an abnormal collection of
fluid in the pleural space resulting from
excess fluid production or decreased
absorption or both.
It is the most common manifestation of
pleural disease.
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Pleural anatomy and physiology
Abnormalities in fluid flow
Manifestations of accumulated fluid
Work up and differential diagnosis
Specific syndromes
Treatment
Anatomy
The pleural space a potential
space between the parietal and
visceral pleura.
PARIETAL PLEURA - covers the
inner surface of the thoracic
cavity, including the
mediastinum, diaphragm, and
ribs.
VISCERAL PLEURA - envelops
all lung surfaces, including the
inter lobar fissures.
ANATOMY
ANATOMY
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Visceral Pleura
Envelops entire surface of
both lungs
⧫ Composed of
mesothelial cells
⧫ Artery Supply:
bronchial arteries
⧫ Lymphatics:
pulmonary parenchyma
⧫ No nerve fibers
⧫ Venous drainage:
pulmonary vein
The visceral pleural surface is seen here at high
power, with a normal mesothelial surface of low
cuboidal cells. There is a thin layer of connective
tissue, below which are peripheral alveolar walls and
alveoli.
Scanning EM of parietal pleura
Parietal Pleura Covers
the inner surface of chest
wall
⧫ Blood supply:
intercostal arteries
⧫ Lymphatics drain to the
thoracic duct
⧫ Pain fibers are present
from intercostal nerves
⧫ Venous drainage : the
superior vena cava
⧫ Normally high fluid flux
1Liter /day
Pleura : Visceral and Parietal
PHYSIOLOGY
The pleural space plays an important role in respiration by
coupling the movement of the chest wall with that of the lungs
in 2 ways.
First, a relative vacuum in the space keeps the visceral
and parietal pleurae in close proximity.
Second, the small volume of pleural fluid, which has been
calculated at 0.13 mL/kg of body weight under normal
circumstances, serves as a lubricant to facilitate movement
of the pleural surfaces against each other in the course of
respirations
PATHOPHYSIOLOGY
Pleural Effusion
The normal pleural space
contains 5-10 mL of fluid,
representing the balance
between
(1) hydrostatic and oncotic
forces in the visceral and
parietal pleural vessels and
(2) extensive lymphatic
drainage.
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Two mechanisms
⧫ Excessive formation
⧫ Fluid resorption is disturbed
Etiology (in decreasing order)
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DISRUPTION
OF BALANCE
Congestive heart failure
Pneumonia
Cancer
Pulmonary embolism
Viral disease
CABG
Cirrhosis with ascites
PATHOPHYSIOLOGY : mechanism
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Altered permeability of the pleural
membranes
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(inflammation, malignancy, pulmonary embolus)
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Reduction in intravascular oncotic
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(hypo-albuminemia, cirrhosis)
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Increased capillary permeability or vascular
disruption
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(trauma, malignancy, inflammation, infection, pulmonary infarction, drug
hypersensitivity, uremia, pancreatitis , infection)
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Increased capillary hydrostatic pressure in the
systemic and/or pulmonary circulation
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(congestive heart failure, superior vena cava syndrome)
pressure
there are no
physical findings
for effusions <300
mL. With effusions
>300 mL, findings
may include the
following:
Common symptoms associated
with
pleural effusion may include:
⧫chest pain,
⧫difficulty breathing,
⧫painful breathing (pleurisy), and
⧫cough (either a dry cough or a productive cough).
Deep breathing typically increases the pain.
⧫Symptoms of fever, chills, and loss of
appetite often accompany pleural effusions
caused by infectious agents
DIAGNOSIS
DIAGNOSIS – Physical Exam
PHY.EX. in pleural
effusion are
variable and
depend on the
volume of the
effusion. Generally,
SIGNS AND SYMPTOMS
CXR: Often the first step
identifying a pleural effusion.
MOST RELIABLE FINDINGS:
Dullness to percussion,
decreased tactile fremitus,
and asymmetrical chest
expansion, with diminished
or delayed expansion on the
side of the effusion
Diminished
or inaudible
breath
sounds
Mediastinal shift
away from the
effusion - effusions
of greater than 1000
mL
Egophony - ("e" to
"a" changes) at the
most superior
aspect of the
pleural effusion
Pleural friction
rub
Pleural effusions appear on chest X-rays as white space
at the base of the lung.
If a pleural effusion is likely, additional X-ray films may
be taken while a person lies on his side.
Decubitus X-ray films can show if the fluid flows freely
within the chest.
Layering of an effusion on lateral decubitus
films defines a freely flowing effusion .
Effusions of more than 200 mL are usually
apparent as blunting of the costophrenic
angle on upright posteroanterior chest
radiographs.
Meniscus Sign
Blunting of the CP Angle
⧫Fluid
Normal Rt costophrenic angle
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rises higher
along the edge of
a pleural effusion
producing a “U” or
meniscus shape.
⧫The meniscus is a
good indicator of
the presence of a
pleural effusion.
Blunted Lt costophrenic
angle
When 200-300cc of fluid accumulate in pleural space, the
usually acute costophrenic angle becomes blunted
Effect of Position - Layering
Loculated Effusion
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Occurs secondary to
adhesions which form
between visceral and
parietal pleura.
Adhesions more common
with blood
(hemothorax) and pus
(empyema).
Loculated effusions have
unusual shapes or positions
in thorax e.g. remain at
apex on erect films.
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Erect
Supine
In the supine position, the fluid layers out posteriorly and
produces a haziness, especially near the bases.
In the erect position, the fluid falls to the bases.
Lateralized Diaphragmatic Dome in
Subpulmonic Effusion
Normal
Previously Normal Film
Right Lateral Decubitus
Subpulmonic effusion
Subpulmonic PE
DIAGNOSIS – CT SCAN
Compared to
chest X-rays, CT
scans produce
more detailed
information about
pleural effusions
and other lung
abnormalities.
CT Bilateral Pleural Effusions
DIAGNOSIS – CT SCAN
Chest CT scanning with contrast should be performed in
all patients with an undiagnosed pleural effusion, to detect
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Thickened pleura or
signs of invasion of underlying or adjacent
structures.
The two diagnostic imperatives in this situation are
pulmonary embolism and tuberculous pleurisy
In both cases, the pleural effusion is a harbinger of
potential future morbidity.
CT angiography should be ordered if pulmonary embolism
is strongly suggested.
DIAGNOSIS - ULTRASOUND
Ultrasound can help guide
drainage; identify whether
pleural effusions are free
flowing. US can aid in the differentiation
of transudates from exudates:
those with septated and
homogenously echogenic
patterns are always exudates,
whereas hypoechoeic
effusions may be either
Pleural Effusion ->Confirmed
Should thoracentesis be
performed?
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If thoracentesis is done
⧫ Is the fluid a transudate
or exudate?
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If the fluid is an exudate
⧫ What is the etiology?
DIAGNOSIS – THORACENTESIS
Thoracentesis
Should be done in almost all patients who
have pleural fluid that is ≥ 10 mm in thickness on CT,
ultrasonography, or lateral decubitus x-ray and that is
new or of uncertain etiology.
In general, the only patients who do not require
thoracentesis are those who have heart failure with
symmetric pleural effusions and no chest pain or fever;
in these patients, diuresis can be tried, and thoracentesis
avoided unless effusions persist for ≥ 3 days.
Pleural fluid analysis
Bloody
Hct
<1% not significant, 1-20%= CA, PE, Trauma
>50% serum Hct = hemothorax
Cloudy
trig level >110mg/dl = chylothorax
cholesterol
Putrid odor
50-110 = intermediate ! lipoprotein analysis
<50 excludes chylothorax
>250 mg/dL = pseudochylothorax
stain and culture = infection?
Transudate vs Exudate?
Exudate vs Transudate
Patient’s serum protein is normal
⧫ Pleural protein is less than 25 g/l
=Transudate
⧫ Pleural Protein more than 35 g/l
= Exudate
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Pleural fluid is exudate if one or more:
Pleural fluid protein:serum protein > 0.5
Pleural fluid LDH:serum LDH > 0.6
Pleural fluid LDH > 2/3 upper limit nl serum
LDH
If not ! Light’s criteria
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MOST TRANSUDATES
HAVE A TOTAL PROTEIN
OF <3 GM/DL
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TB PLEURAL EFFUSION
>4GM/DL
IF THE PROTEIN
CONCENTRATION IS > 7-8
GM/DL, CONSIDER
WALDENSTROMS
MACROGLUBULINAEMIA
OR MULTIPLE MYELOMA
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LDH >1000,
COMMONLY SEEN
IN Empyema,
Rheumatoid
pleurisy and
Malignancy
Transudate
Exudate
CHF
Pneumonia
Cirrhosis
Malignancy
Nephrotic syndrome
Pulmonary Embolism
Additional studies
LDH
PROTEIN
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Light’s Criteria
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Cell count -
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Culture/stain- infected fluid
Glucose
Cytology- malignancy
pH- parapneumonic <7.2 -must drain fluid
malignant < 7.2 –poor prognosis
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Neutrophil predom
Lymphocytic predom
acute pleural process
chronic process
Pleural fluid pH
PLEURAL FLUID GLUCOSE
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A LOW PLEURAL FLUID GLUCOSE CONCENTRATION <60 MG/
DL OR PLEURAL FLUID/SERUM GLUCOSE <.5 NARROWS THE
DIFFERENTIAL
CAUSES:
Malignant effusion
⧫ Tuberculous pleuritis
⧫ Esophageal rupture
⧫ Lupus pleuritic
⧫ Complicated parapneumonic
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A very low pleural glucose concentration (i.e.< 30 mg/d L) further
restricts diagnostic possibilities, to rheumatoid pleurisy or
empyema
Pleural fluid pH is highly correlated with pleural fluid glucose
levels
A pleural fluid pH of less than 7.30 with a normal arterial
blood pH level is caused by the same diagnoses as listed
above for low pleural fluid glucose.
In parapneumonic effusions a pleural fluid pH of less than
7.15 indicates the need for urgent drainage of the effusion,
while a pleural fluid pH of more than 7.3 suggests that the
effusion may be managed with systemic antibiotics alone.
In malignant effusions, a pleural fluid pH of less than 7.3 has
been associated in some reports with more extensive pleural
involvement, higher yield on cytology, decreased success of
pleurodesis, and shorter survival times
Cell Count of Exudative Effusions
Pleural fluid Amylase
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Greater than upper limits of normal for
serum amylase or pleural fluid/serum ratio
>1.0
Causes
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Acute pancreatitis
Esophageal rupture
Malignancy
Chronic pancreatic pleural effusion
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Lymphocytic (> 50%)
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Empyema
Parapneumonic
Rheumatoid
Pulmonary infarction
PMN or Lymphocytic
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PE
Conn tissue disease
Post-cardiac injury
Eosinophilic (> 10%)
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PMNs
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CA
TB
Sarcoidosis
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Trauma
PTX
CA
Asbestos, parasites
Pneumonia
RBC > 100,000/mm
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CA
Trauma
Pulmonary infarction
PLEURAL FLUID EOSINOPHILIA
Pleural fluid eosinophilia (PFE), with values greater than 10% of
nucleated cells, is seen in approximately 10% of effusions.
No correlation with peripheral blood eosinophilia.
PFE is most often caused by air or
space – trauma, pneumothorax
blood in the pleural
PFE may be the result of pulmonary
embolism with
infarction or benign asbestos pleural effusion.
PFE may be associated with nonmalignant diseases:
parasitic disease , fungal infection, various
medications, and Chrug-Strauss Syndrome
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Adenosine deaminase
High levels of ADA are commonly
seen in tuberculous effusions, but
false positives (especially with
empyema, rheumatoid effusions,
and lymphomas) do occur.
Since less than 40% of TB pleural
effusion have positive pleural fluid
⧫ Routine measurement of ADA is
culture, alternative means such as the
not encouraged in non-endemic
level of ADA, interferon gamma, or
areas.
In
PCR are used to confirm a diagnosis
endemic areas,
however, a low pleural
fluid ADA effectively
excludes pleural
tuberculosis.
The presence of PFE makes tuberculous
pleurisy as well as empyema unlikely.
Mesothelial cells > 5% of total nucleated
cells makes a diagnosis of TB less likely.
TUBERCULOUS PLEURAL EFFUSION
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MOST PATIENTS PRESENT WITH PLEURITC CHEST PAIN
TUBERCULOSIS TOXIC SYNDROME : DRY COUGH,LOW
GRADE FEVER, NIGHT SWEAT AND LOSS OF WEIGHT.
POSITIVE TUBERCULIN- PPD- TEST, SIGNIFICANTLY HIGH ADA LEVEL
IN PLEURAL FLUID (ADA ACTIVITY OF > 50 U/ML)
EXUDATIVE EFFUSION WITH MARKEDLY ELEVATED PROTEIN LEVEL
>50 GM/L.
IFN GAMMA CONCENTRATION >140 p g/ml SUPPORT THE DIAGNOSIS
DIFFERENTIAL WHITE CELL COUNT SHOWS > 80% LYMPHOCYTES.
PLEURAL BIOPSY HAS GOT THE GREATEST UTILITY IN
ESTABLISHING THE DIAGNOSIS.
DEMONSTRATION OF CASEATING GRANULOMA AS WELL AS ACID
FAST BACILLI AS THE CONFIRMATORY PROOF
Other tests?
WHY DO WE TREAT TB EFFUSION?
Tuberculous pleuritis is typically self-limited.
If not treated the effusion will resolve but pulmonary or
extra pulmonary tuberculosis subsequently develops
in >65% of patients within five years.
Empiric TB rx is the option, pending culture results
when sufficient clinical suspicion is present, such as
an unexplained exudative or lymphocytic effusion in a
patient with a positive PPD finding
Tumor markers
is no routine clinical role for these at present.
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Rheumatoid factor, antinuclear antibody, complement
fluid values mirror serum levels and are of little
additional benefit.
⧫Pleural
Bronchoscopy
majority of pleural effusions seen in clinical practice are not
associated with a lung parenchymal abnormality as the cause.
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⧫ Bronchoscopy
is therefore only advised if the patient has
symptoms such as hemoptysis or CT features suggesting
endobronchial involvement.
PARAPNEUMONIC EFFUSION
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Any pleural effusion associated with bacterial
pneumonia, lung abscess, or bronchectasis
Gram stain and bacterial culture will identify infected
pleural fluids
Effective antibiotic therapy is the key issue for
controlling infection
When pleural fluid analysis meets any of the
following criteria, chest tube drainage should be
considered:
DRESSLER’S SYNDROME
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1.EMPYEMA
2.PLEURAL FLUID CULTURE IS POSITIVE
3.PLEURAL FLUID GLUCOSE IS LESS
THAN 40 MG%
4.PLEURAL FLUID pH <7.15
Post-cardiac injury syndromes
Post-CABG effusions are common
Exaggerated immune response to cardiac antigens
Pleuritc chest pain, fever, High ESR,
leukocytosis, anti-myocardial antibodies
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PMN leukocytosis <30 DAYS; later lymphocytosis
Present average 3wks after, but can be up to 1 yr
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NSAIDS AND STEROIDS AS TREATMENT
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MALIGNANT PLEURAL EFFUSION
IDIOPATHIC EXUDATIVE EFFUSIONS
- The second most common type of
exudative effusion
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- Malignant pleural effusions signify
INCURABLE DISEASE (Stage IV)
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- The 3 tumors that cause approx. 75% of
malignant effusions are: LUNG, BREAST &
LYMPHOMA
Mean survival < 1 year
RECURRENT MASSIVE EFFUSIONS MAY
NEED REPEATED THORACENTESIS,
PLEURODESIS OR PLACEMENT OF
INDWELLING TUNNELED CATHETERS
WHICH PROVIDES GOOD PALLIATION
MANAGEMENT OF PLEURAL EFFUSION
Medical Management:
❖ Antibiotics
❖ Analgesics
❖ Diuretics
❖ Cardiotonic Drugs
❖ Thoracentesis
❖ Chest tube
❖ Pleurodesis
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Despite repeat thoracenteses, approximately 20% of
exudative effusions remain undiagnosed
May be BENIGN ASBESTOS PLEURAL EFFUSION (BAPE)
from exposure to asbestos up to 20 yrs ago
DRUG INDUCED ( NITROFURANTOIN, AMIODARONE,PHENYTOIN,METHOTREXATE )
DRUG INDUCED LUPUS
HEPATIC HYDROTHORAX WITH MINIMAL OR
UNDETECTABLE ASCITES
(In practice, many patients with undiagnosed effusions
eventually turn out to have malignancy)
PLEURODESIS
Pleurodesis is performed to
prevent recurrence of
pneumothorax or recurrent
pleural effusion.
Involves instilling an irritant
into the pleural space to cause
inflammatory changes that
result in bridging fibrosis
between the visceral and
parietal pleural surfaces.
BEYOND THORACENTESIS
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Pleural Biopsy
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Most helpful in evaluating for TB
Limited utility for CA
Thoracoscopy
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Most helpful in
evaluating for
malignancy